Trust. Limited Liability Company, Partnership and Estate Supplemental Application

TRUST, LIMITED LIABILITY COMPANY, PARTNERSHIP AND ESTATE
SUPPLEMENTAL APPLICATION

(To be used in conjunction with Company applications PUMBAPP and PUMBAPP-R
or an ACORD Personal Umbrella Application)

Named Insured/Applicant:Policy Number:

Full name of the trust, Limited Liability Company (LLC), Partnership or estate (hereafter, “entity”):

Mailing Address of entity:

1.Date entity was established:

2.For what purpose was the entity formed?

3.Has the purpose of the entity changed since its formation?...... Yes No

If “Yes,” explain:
4.List all trustee(s), LLC owner(s) or member(s), partner(s), estate administrator(s) and/or executor(s) and their occupation(s) (if self-employed, explain):

5.Within the past five years, has the entity engaged in any form of business activity or owned any real estate for business purposes whether or not identified on the application? Yes No

If “Yes,” explain:

6.Within the past five years, has the entity been the subject of litigation of any kind?...... Yes No

If “Yes,” explain:

7.Does the entity have any employees?...... Yes No

If “Yes,” provide the number of employees and their job responsibilities:

8.Does the entity own any real estate, personal property or assets not listed on the application?...... Yes No

If “Yes,” identify those exposures:

Complete the attached schedule to include all exposures owned, in whole or in part, by the entity.

REAL ESTATE
List all properties in which the entity has ownership (residences, buildings, farms, vacant land, etc.)
(Attach separate sheet, if necessary.)
No. / Location / Description / Year Built / Underlying Limits of Liability
Bodily
Injury / Property
Damage
1
2
3
4
AUTOMOBILES, RECREATIONAL VEHICLES, VEHICLES, MOTOR HOMES, MINIBIKES, ETC.
List all vehicles in which the entity has an ownership interest. (Attach separate sheet, if necessary.)
No. / Year / Vehicle Type, Make and Model / Underlying Limits of Liability
Bodily
Injury / Property
Damage
1
2
3
4
WATERCRAFT
List all watercraft in which entity has an ownership interest. (Attach separate sheet, if necessary.)
No. / Year / Type, Manufacturer
and Model / Length / HP / Max.
Speed / Underlying Limits of Liability
Bodily
Injury / Property
Damage
1 / ft
2 / ft
3 / ft

This supplement does not bind YOU nor US to complete the insurance, but it is agreed that the information herein shall be the basis of the contract should a policy be issued.

Refer to Application form for State Fraud Warnings

APPLICANT’S STATEMENT:

I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kansas: This does not constitute a warranty.)

APPLICANT’S SIGNATURE: DATE:

CO-APPLICANT’S SIGNATURE: DATE:

PRODUCER’S SIGNATURE: DATE:

AGENT NAME: AGENT LICENSE NUMBER:

(Applicable to Florida Agents Only)

IOWA LICENSED AGENT:

(Applicable in Iowa Only)

IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided.

PUZ-SUPP-1 (11-16)Page 1 of 3